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Health Records and Health Information Management (CH25)

The common function of the health information management department is to:
Provide availability, accuracy, and protection of clinical info
Health records are more commonly completely:
Electronic; but can be scanned and stored as computerized images.
Miniature form
Clinical decision making and financial reimbursement depend on the:
Information contained in the health record
Federal legislation passed to improve the efficiency and effectiveness of the health care system; components that affect health information include privacy, security, and the establishment of standards and requirements for the electronic transmission of certain health information
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Coding involves converting diagnoses and procedure into a:
numeric classification system
System for Medicare patients by which a predetermined level of reimbursement is established before services are provided
Prospective Payment System (PPS)
System that categorizes into payment groups patients who are medically related with respect to diagnosis and treatment and statistically similar with regard to length of stay
Diagnosis-Related Groups (DRGs)
Codes are reported to:
Medicare & other third-party payers, such as Insurance companies
__ __ __ __ must communicate needed data to departments
Health information management practitioners
Health records and radiology records are retained by a facility for a specific amount of time according to the:
Code of Federal Regulations, state law, and accreditation requirements
Health records are to be retained for a minimum of __ years from the date the patient was last seen
5 years
According to the MAMMOGRAPHY QUALITY STANDARDS ACT, a facility must keep a mammogram in the permanent medical record for __ years, or no less than __ years if a patient has had no other mammograms at that facility, or longer is mandated by state law.
no less than 5 years, or no less than 10 years
Standards for the maintenance and the documentation within health records have been established by accrediting agencies such as:
The Joint Commission (TJC), and the American Osteopathic Association via its Healthcare Facilities Accreditation Program (HFAP)
Documenting in the patient’s record
Charting should be done by whom when a patient receives either diagnostic or therapeutic radiologic services?
Radiologists or Radiographers
The health record, per TJC, must contain sufficient information such as:
1. Identify the patient
2 Support the diagnoses
3. Justify the treatment
4. Document the course and results
5. Facilitate continuity of care
A computerized system tracks film and folders with a:
Bar code system
The term __ __ implies that the patient has been informed of the procedure or operation to be performed, the risks involved, and the possible consequences.
Informed consent
__ __ contains information relative to patient incidences or event occurrenes
Incident report
Before a radiologic procedure is performed, a __ is completed
Radiology order for service
A Radiology order for service includes:
1. Patient demographic information
2. Specific procedure being requested
3. Physician order the procedure
If Medicare does not cover the procedure,, the patient is notified and is required to sign:
an advance beneficiary notice (ABN)
The results of the procedure are documented on a:
Radiology report
A __ __ must be completed for every service for which a medical claim will be filed.
Written report
Radiology reports must be included in the patient record to describe:
the radiologic services the patient received
Where do original copies of documents go?
In the patient’s record
__ documentation is not legal in any state.
In a paper record, who is responsible for correcting an error in the documentation?
The person who makes the error
The concept of the DRG is that patients fall into statistically similar, __ __ groups.
Diagnostically related
The health information professional uses the __ __ provided by the __ to code the patient’s information into the classification system.
Diagnosis terminology
The __ is used for procedural classification of inpatient procedures
International Classification of Diseases (ICD-10-CM), Procedure Classification System (ICD-10-PCS)
Using a computer programer called a __, the health information practitioner computes the patient’s DRG.
__ codes are used to code procedures for outpatient encounters and coding for ancillary services such as radiology and laboratory.
Current Procedural Terminology, 4th Edition (CPT-4)
A criticism of DRGs has been that:
the system does not take into account the severity of a patient’s disease.
The __ and __ classification systems are used for inpatient reporting.
ICD-10-CM and PCS
(effective 10-1-15)
For outpatients, hospitals must report the diagnosis using the __ or __ codes and __ codes for the procedures.
The physician’s offices uses the __ codes for the DIAGNOSIS, and the __ coding system for the PROCEDURES.
ICD (International Classification of Diseases)
CPT (Current Procedural Terminology)
Radiology codes in CPT include:
1. Diagnostic and Therapeutic radiology
2. Nuclear Medicine
3. Diagnostic ultrasonography
4. Radiation oncology
Code number range from:
Chest radiograph, single view, frontal, would be coded as:
MRI of the cervical spine with contrast media is coded to:
List the 4 data tables in the IRD database:
1. Anatomical
2. Sub-anatomical
3. Pathological
4. Sub pathological
__ __ is a process by which the quality of the care and services provided to patients within a health care facility are monitored and elevated.
Performance improvement
The terms __ __, __ __, and __ __ are all used to encompass activities related to performance improvement
quality assurance, quality assessment, and performance improvement
List the dimensions of performance:
1. Efficacy
2. Appropriateness
3. Availability
4. Timeliness
5. Effectiveness
6. Continuity
7. Safety
8. Efficiency
9. Respect & caring
The __ __ is an important legal document that the health care institution uses to define what was or was not done to the patient.
Patient record
What is the proper method for correcting an error that an author makes in a health record?
Draw a single line through the error, write “ERROR”, record the correct info., date & sign.
Which of the following is not a function of a hospital health information management department?
1. Coding of diagnoses and operative procedures and diagnosis-related group assignment
2. Documenting relevant patient information in the medical record
3. Quality management and performance improvement activities
4. Appropriate release of medical information
Documenting relevant patient information in the medical record
The prospective payment system is a payment system based on?
the diagnosis-related group (DRG) or the ambulatory patient classification (APC)
Which of the following is an example of an organization that accredits hospitals and other health care institutions in the US?
The Joint Commission
The chief complaint, included in a patient’s history, is a statement made by the:
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) legislation affects radiology and other hospital departments by its focus on:
Patient record confidentiality
Which of the following is not required to be included in a patient’s health record?
1. Medical history
2. Radiology reports
3. Patient’s telephone number
4. Physical examination report
Patient’s telephone number
Criteria used in performance improvement activities must be all of the following EXCEPT:
1. Clinically valid
2. Diagnosis or procedure oriented
3. Generally acceptable to department staffs
4. Written
Diagnosis or procedure oriented
Assessment of problems in performance improvement activities must be:
In making a correction to an entry in the paper health record, the documenter should:
line out the error, authenticate, and insert correct information
The organization (chart orders, forms) of a hospital patient record is determined by:
the hospital’s own preference

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